Atrial flutter: more than just one of a kind.
Sok-Sithikun Bun, MD1,*
Authors:
Decebal Gabriel Latcu, MD1
Francis Marchlinski, MD2
Nadir Saoudi, MD, FESC.1,2
Authors’ institutions:
1
Department of Cardiology, Princess Grace Hospital,
Monaco (Principality).
2
Cardiology Division, Section of Electrophysiology, University of
Pennsylvania
USA.
Corresponding author and/or reprint requests:
*Dr Sok-Sithikun Bun
Department of Cardiology, Princess Grace Hospital,
Pasteur Avenue, Monaco (Principality)
Phone: +33662898314
Fax: +37797989732
Email: sithi.bun@gmail.com
Figure legends
Figure 4. Recurrent atrial flutter in a 80 years-old patient with previous successful
cavotricuspid isthmus (CTI) ablation six months earlier. ECG suggests a recurrent
counterclockwise CTI-dependent flutter, but entrainment manoeuvers (post-pacing
interval- cycle length) revealed a participation of the septal CTI (circuit depicted with
the red arrow), and proximal coronary sinus as part of the circuit, confirming the
presence of an intra-isthmus reentry (reproduced with permission). Red dotted lines
represent the previously blocked CTI line.
Figure 6. Three-dimensional electroanatomical biatrial maps in antero-posterior (left)
and postero-anterior view (right image) of a 83 years-old male who presented with a
recurrent atrial flutter 8 years after initial successful cavotricuspid isthmus (CTI)
ablation. Surface ECG is compatible with a typical counterclockwise flutter, but
activation map reveals a focal source (red star) from left atrial anterior wall with
passive right atrial activation; since the previously created block through the CTI still
exists, activation of the right atrial free wall is not a collision of two activation fronts
as it would be expected in case of left atrial origin, but is now descending. Thus, a
large part of the tricuspid annulus has a counterclockwise activation pattern,
responsible for the “pseudo-typical” ECG pattern in inferior leads.
Figure 8. Atrial flutter ECG in a 49 years-old female patient, without structural heart
disease, with previous pulmonary vein isolation procedure. The F-wave is bifid in
inferior leads during tachycardia (left) but the p wave during sinus rhythm is not
modified (lower image). Tachycardia was a microreentry caused by a reconduction at
the left superior pulmonary vein level, as recorded on a circular mapping catheter (PV
3-4 to PV 15-16) on the right image. A single radiofrequency burn with the ablation
catheter (ABL d and p) successfully eliminated the tachycardia. The electrograms on
the coronary sinus catheter are also shown from proximal (CS 9-10) to distal (CS 34).
Figure 4.
Figure 6.
Figure 8.